Application Form and Guidance Notes

APPLICANTS WILL NOT BE ENTITLED TO COUNCIL HOUSING BY BEING A RESIDENT AT ANY YMCA LONDON CITY AND NORTH ACCOMMODATION PROJECTS

Please make sure you read the privacy notice document and signed the consent form, also refer to the guidance before filling in the application form.

ALL SECTIONS OF THE APPLICATION MUST BE COMPLETED TO AVOID DELAY

Please indicate which service you are referring to:

Monarch Court

Any questions in relation to completion of this form, please contact:

mcreferrals@cityymca.org

LandAid House

Any questions in relation to completion of this form, please contact:

lahreferrals@ymcalcan.org

Crouch End

Any questions in relation to completion of this form, please contact:

cereferrals@ymcalcan.org

Applicant's Name

Date

Application Form and Guidance Notes

Please click this link to read the Application Form and Guidance Notes

Service Users Privacy Policy

Please click this link to read the Service Users Privacy Policy

Service Users Consent Form

Applicants are required to confirm that they have read and understood the Service User Privacy Policy above.

Please download the Service Users Consent Form and upload a signed copy then confirm the consent provided and who signed in the fields below.

Please upload the signed consent form here

General Consent

General consent given

Who signed?

Date consent form signed

Housing and Youth Services Consent

Housing and Youth Services Applicable

Housing and Youth services consent

Who signed?

Housing & Youth Services consent date

Image Capture and Release Consent

Image capture and release consent

Who signed?

Image capture and release consent date

Applicant Details

First Name

Surname

Address 1

Address 2

Town / City

County

Postcode

Marital status, Birthdate, etc

Marital Status

Date of birth dd/mm/yyyy

Telephone 1

Telephone 2

Email Address

Please enter below the National Insurance Number for the young person applying to YMCA London City And North. We will not be able to process their application for assistance without it. It must be entered in the format XX123456X.

National Insurance Number

Applicant Details Continued

1) Do you have dependent children?

2) Have you ever been a member of the armed forces?

3) Next of Kin Details

Title	Name
Address 1 County Postcode Mobile Fax	Address 2 Town/City Country Telephone

Email address

Relationship to client

Suitable to contact

Additional Details

4) What is your religious belief?

Other religious belief

5) What is your sexual orientation?

6) Do you consider yourself transgender?

Immigration section

7) Immigration status

Other Immigration status

8) What do you consider as your ethnic group?

Other ethnic background

9) Country of Origin?

Nationality?

Latest accommodation

17) Which area were you living in when you became homeless?

18) Please indicate which type of accommodation you occupied last/are occupying now:

Length of Time in Local Area

19) How long have you lived in the local area?

20) Do you have immediate family living in the local area

21) Are you currently employed/being trained in local area

22) Have you ever had a previous residence of over 5 years in the local area?

Previous Evictions

Have you ever been evicted?

Reason:

Has the Young Person lived in more than one accommodation in the last five years?

Housing History

		Address
	Address Line 1 Address Line 2 Town County Postcode Country	Date from: Date to Reason for Leaving Did you leave with arrears? If so, how much?

Health Section

Health History:

Please give details of any health problems past and present you have, the support that you need to help you with these problems and details of any medication prescribed by your doctor (include and significant health history).

Physical Health

Past Health Issues

Current Health Issues

Medication

What type of support are you getting:

26) Do you have any disabilities?

Do you have any specific needs in relation to any of the following?

Full wheelchair accessible housing	Wheelchair access to essential rooms
Level access housing	Adaptions for visual impairment
Adaptions for hearing impairment	Other disability related requirements
No disability related requirements	Don't know

35) Are you pregnant?

Do you know your Doctor's details?

Doctors Details

Dr's Name	Surgery
Address Line 1 Town Postcode	Address Line 2 County

Email

Telephone

Mobile

Do you know your Dentist's Details?

Dentist Details

Dentist Name

Dental Practice

Address Line 1

Address Line 2

Town

County

Postcode

Telephone

Mobile

Email

Health Section Continued

Mental Health History

Please give details of any mental health problems you have now or have had in the past. This could include, for example, depression, anxiety, being paranoid, self-harm or suicide attempts.

Past Mental Health Issues?

Current Mental Health Issues?

Medication?

What type of support are you getting?

Have you ever self-harmed?

If yes, how and why?

Have you experienced suicidal thoughts or attempted suicide?

Mental Health Worker

Are you seeing / have you seen a mental-health worker?

Mental-Health Worker information

If yes who?

Which agency or organisation?

Address Line 1

Address Line 2

Town

County

Postal Code

Email

Phone

Mobile

Please give details of support needs due to mental health

Alcohol, Drugs / Substance Use History

Using Alcohol and / or drugs will not prevent you from being re-housed. Telling us about your substance use will help accommodation providers think about any risk to you or others and help them provide appropriate support. This includes cannabis, alcohol, pills, glue/solvents as well as harder drugs such as heroin or crack. Include prescribed medication if it was or is misused.

Alcohol, Drugs / Substance used now and in the past

Length of time used

How much / often do you used and the main problems it causes you

Support Agency used, name of worker and telephone number

Please give details of any support needs due to alcohol, drugs / substance use

Crimes against you

36) Have you recently been a victim of domestic violence?

37) Have you recently been a victim of racial harassment?

38) Have you recently been a victim of hate crime?

Have you been accepted as requiring services under the following statutory frameworks?

39) Care Management (Social Services)

40) Secondary Mental Health Service

41) Probation Service or Youth Offending Teams

43) Drug Intervention Programme

Have you been assessed at higher risk under any of the following?

43) Care Programme Approach

44) Multi Agency Public Protection Arrangements (MAPPA)

Multi Agency Risk Assessment Conference (MARAC)

Have you ever been convicted of any of the following?

Tell us even if the offence is 'spent'

46) Arson

47) Violent Offences

48) Sexual Offences

49) Offences Against Children

50) Racially Motivated Offences

51) Religious Motivated Offences

Offences / Court Cases / Orders

52) Are there any outstanding offences or court cases you are on bail for or waiting to hear about?

53) Are you currently subject to requirements under a Criminal Protection Order or Criminal Behaviour Order?

Give details of the Criminal Protection Order (CPN) or Criminal Behaviour Order (CBO) (Why, Dates and Conditions)

Offending / Criminal History

Do you have any cautions / referral orders / convictions / warnings?

Caution or Conviction

Date of caution / referral order / conviction / warning

Caution, Referral Order, Conviction or warning?

Offence

Sentence and any conditions

Are there any No Go Areas?

Are there any Geographical Bail Restrictions?

Name & Contact details of Probation / YOT

Court Appearances

Do you have pending Court appearances?

If yes, why?

Have you ever appeared in Court?

If yes, why?

Statement - Why YMCA London City And North Accommodation

Residents are required to attend regular key working meetings and work towards the Outcome Star Model. Please say why you want to live in YMCA London City And North housing. (Don't tell us what support you need; we'll ask you about that later, just say why you want to live in our accommodation.)

Statement

Any other needs?

Immediate or longer-term needs

Other support needs

Do you have any support needs we need to be aware of before your initial Housing Assessment e.g. physical disability or the need for an interpreter?

Do you have any other information you would like YMCA London City And North to be aware of in consideration of your application, including a preference of provided accommodation (with reasons)?

Referral Agency Details

All sections must be completed

Referrers Name

Agency

Address Line 1

Address Line 2

Town

County

Postal Code

Email

Telephone

Mobile

Relationship to Applicant (eg Housing Advisor)

How long have you known Him / Her?

Briefly say why you are making this referral

Submitting this application form

Please review the application with the young person applying by clicking submit below. Once you are ready to proceed you will be taken to a further page to access a copy of the declaration form. The young person will need to sign this declaration and you will need to upload a copy to complete the form.

Alone in London	Central Care	Centrepoint
Community Mental Health Team	Crisis	Depaul Trust UK
Glass Door	Greenhouse	Hackney Council
Housing Option Team	London CRC	Manna Society
New Horizon	No First Night Out	No Second Night Out
One Housing	Other Agency	Out of hours Social Services
Panel (Team Around Child/Joint Referral Plan)	Probation service/probation	Providence Row
Shelter From The Storm	Social Services	St Giles Trust
St Mungos	Thamesreach	The Pilion Trust
Tower Hamlets Council	Waltham Forest Council	Westminster Housing Option
YOT

Homeless - Squatting	Homeless - Sofa Surfing	Homeless - Sleeping Rough
Asked to leave by family or friends	Left home country as a refugee	End of tenancy
Evicted	Independent Living	Leaving Care
Leaving Prison	No fixed abode	Relationship breakdown
Overcrowding	Poor condition	Moved on for security
Domestic Violence	Learning disabilities	Discharged from Mental Health Hospital
Discrimination	Harassment	Abuse
Gang problems	Move out of temporary accommodation	Discharged from Hospital
Required to move out of shared housing/hostel	In need of supported housing	To be near family, friends or employment
Could not afford rent	Financial problems

Alcohol misuse problems	Drug misuse problems
Gypsies & Travellers with support needs	Learning disabilities
Mental health problems	Offenders or at risk of offending
People at risk of domestic violence	People with HIV/AIDs
Physical or sensory disability	Refugees
Rough sleeper	Single homeless with support needs
Teenage parents	Young people at risk
Young people leaving care	Generic/complex needs

Alcohol misuse problems	Drug misuse problems
Gypsies & Travellers with support needs	Learning disabilities
Mental health problems	Offenders or at risk of offending
People at risk of domestic violence	People with HIV/AIDs
Physical or sensory disability	Refugees
Rough sleeper	Single homeless with support needs
Teenage parents	Young people at risk
Young people leaving care	Generic/complex needs

Alcohol misuse problems	Drug misuse problems
Gypsies & Travellers with support needs	Learning disabilities
Mental health problems	Offenders or at risk of offending
People at risk of domestic violence	People with HIV/AIDs
Physical or sensory disability	Refugees
Rough sleeper	Single homeless with support needs
Teenage parents	Young people at risk
Young people leaving care	Generic/complex needs

Full time student	Full time work - more than 24 hours per week
Job seeker	Unable to work (Long-term sick / disabled)
Part time work - less than 24 hours per week	Did not ask
Client did not wish to disclose	Upcoming employment
Part-time training	Upcoming student
Full-time training	Upcoming training
Not in employment	Part-time student
Not in education	Not in training

Personal Independence Payment	Income Support
Employment & Support Allowance	Loans
Housing Benefit	Jobseeker's Allowance
Universal Credit	Council Tax Benefit

Budgeting for bills/day to day living	Claiming benefits
Housing / Council Tax benefits	Paying rent or other bills
Managing debts	Maximising Income
Any other financial issues

Ability to maintain a clean and tidy environment	Washing and ironing
Ability to cook a meal from start to finish	Knowledge of healthy eating
Health and Safety

Physical Health	Registering with a GP / Dentist
Increase Support Network	Sexual Health
Sexual Identity	Drug and Alcohol issues
Develop healthy relationships	Managing time effectively
Cultural or Religious needs	Equal opportunities and diversity
Welfare rights	Mental Health
Counselling	Mediation
Accessing specialist offender services	Accessing other services
Citizenship and 'getting involved'	Keeping yourself safe
Parenting skills	Personal Development / Social activities / Contacts

Job applications	Writing a CV
College / training applications	Interview skills
Accessing training / courses	Basic skills (e.g. reading and writing, maths skills) / English needs

Application Form and Guidance Notes

Housing

Health Section Continued

Offending / Criminal History

Initial Support Assessment

Any other needs?

Referral Agency Details

Submitting this application form